Anaphylaxis due to infusion of chemicals and biological products in cancer treatment

Anaphylaxis due to infusion of chemotherapy and biological products in cancer treatment can occur at any time, usually shortly after the drug is first introduced into the patient's body or within the first hour and can occur. occur during any course of treatment.

Anaphylaxis is essentially an allergic reaction, which can appear immediately from a few seconds, minutes to hours after the body is exposed to the allergen, causing different clinical manifestations, which can be very severe. severe and lead to rapid death. Anaphylaxis is the most severe form of anaphylaxis caused by sudden systemic dilation and bronchospasm and can be fatal within minutes.
The cause of the immediate reactions is due to the interaction between antigens and antibodies, the release of cytokines and chemical mediators... Because of its serious and unexpected nature, early detection is essential. and timely treatment to avoid death for the patient.

Healthcare workers may think of anaphylaxis when one of the following symptoms is present:
Urticaria, rapid angioedema Shortness of breath, stridor, chest tightness Abdominal pain or vomiting Low blood pressure or fainting Disorders of consciousness.

Clinical picture 1
Symptoms appear in seconds to hours after infusion of chemicals and biological products:
In skin, mucous membranes: Urticaria, pruritus, angioedema.
Presence of at least 1 of the following 2 symptoms:
Respiratory symptoms: Shortness of breath, stridor, auscultation with rales in the lungs Consciousness or drop in blood pressure, urinary incontinence. Clinical picture 2
At least 2 out of 4 of the following symptoms appear within seconds to hours after infusion of chemicals and biological products:
Skin, mucous membranes: Pruritus, urticaria, angioedema Symptoms Respiratory symptoms: Shortness of breath, stridor, auscultation with rales in the lungs Consciousness or drop in blood pressure, urinary incontinence Gastrointestinal symptoms: Abdominal pain, vomiting. Clinical picture 3
Hypotension occurring within seconds to hours after infusion of chemotherapy and biological products:
Children: Decrease in systolic blood pressure (maximum blood pressure) by at least 30% or A decrease in systolic blood pressure for age (systolic blood pressure <70 mmHg). Adults: Systolic blood pressure <90 mmHg or 30% reduction from baseline.

Histamine in the blood: Best within 1 hour, peak concentration reached after 10 minutes Tryptase: Peak concentration reached after 2 hours High levels of histamine and tryptase are diagnostic of anaphylaxis immediately, but if not increased, it is not possible. excluding anaphylaxis.

Cases of shock: Cardiogenic shock, septic shock, hypovolemic shock, ... Cerebrovascular accident Causes of airway obstruction: bronchial asthma, COPD, causes of airway obstruction (allergies) organism, inflammation). Skin diseases: Angioedema, urticaria... Endocrine diseases: Thyroid storm, hypoglycemia, carcinoid syndrome Poisoning: Alcohol, opiate, histamine.

There are 4 levels:
Mild (grade I): Prominent skin and subcutaneous tissue symptoms: urticaria, itching, angioedema...
Severe (grade II): Having 2 or more symptoms and manifestations present in many organs
Urticaria, itching, angioedema appear rapidly. Shortness of breath, rapid shallow breathing, chest tightness, stridor, runny nose, hoarseness... Disorders of consciousness: Struggling, convulsions, coma, circular muscle disorders... Circulatory: Shock, hypotension, small rapid pulse... Critical (grade III): Manifestations in many organs with more severe degree as follows:
Airway: laryngeal stridor, laryngeal edema Respiratory: Tachypnea, wheezing, confusion breathing, cyanosis Consciousness disturbances, coma, convulsions, circular muscle disorders Circulatory: Pulse collapse, hypotension Circulatory arrest (grade IV): There are signs of respiratory arrest, circulatory arrest.

All cases of anaphylaxis should be detected early, treated urgently, promptly on the spot and monitored for at least 24 hours. Doctors, nurses, midwives, students, technicians and other healthcare workers are all responsible for providing first aid for anaphylaxis and anaphylaxis. Adrenalin is an essential drug, the first important to save the life of patients with anaphylaxis, must be administered intramuscularly immediately, diagnosed anaphylaxis grade II or higher.

Allergies can progress to severe and serious Use methylprednisolone or diphenhydramine oral or injectable depending on the patient's condition. Continue to monitor the patient for at least 24 hours for further management.

Grade II anaphylaxis can quickly progress to grade III, grade IV, so it must be treated urgently and at the same time depending on the disease progression. Immediately stop infusion of chemicals or biological products Inject or infuse adrenaline according to protocol. Have patient lie down, head low, left side tilted if vomiting occurs Oxygen: flow rate in adults 6-10 liters/min, children 2-4 liters/minute through open mask Assess respiration, circulation, Consciousness and skin and mucosal manifestations of the patient Perform external chest compressions and balloon compressions (if the patient is respiratory and circulatory arrest) If laryngeal dyspnea requires endotracheal intubation or tracheostomy emergency. Establish an intravenous adrenaline line with a conventional line but a large needle (size 14 or 16G), or place a second line or intravenous catheter for rapid infusion. Consult with colleagues, focus on management, report to superiors, consult with emergency medicine, resuscitation and or allergist (if necessary).

Objectives: raise and maintain stable systolic blood pressure ≥90mmHg, children ≥70mmHg, and no longer have respiratory signs such as dyspnea, stridor, gastrointestinal signs such as vomiting, diarrhea.
Adrenaline 1mg =1 ml = 1 tube, administered intramuscularly:
Infants or children <10kg: 0.2ml (equivalent to 1/5 ampoules) 10kg children: 0.25ml (equivalent to 1/4 ampoule) Children 20kg: 0.3ml (equivalent to 1/3 tube) Children > 30kg: 0.5ml (equivalent to 1/2 tube) Adults 1/2-1ml (1/2-1 tube) Monitor blood pressure 2-5 minutes/time
Need to repeat adrenaline dose as above every 3-5 minutes until pulse and blood pressure stabilize.
If pulse is not detected or blood pressure cannot be measured, respiratory and gastrointestinal symptoms worsen after 2 to 3 intramuscular injections of the above dose, or the patient is at risk of circulatory arrest, immediate action should be taken:
In case no intravenous line is available: Slow intravenous injection of adrenaline with a solution of 1/10,000 (1 ampoule of 1mg adrenaline mixed with 9ml of distilled water to make a 1/10 dilution). The slow intravenous dose of adrenaline in anaphylaxis is only one-tenth the dose of adrenaline in cardiac arrest. Dosage is as follows: + Adults: 0.5-1ml (1/10,000 dilution solution) injected within 1 to 3 minutes, after 3 minutes can be given a second or third injection if pulse and blood pressure are not up. Immediately switch to continuous intravenous infusion once an intravenous line has been established.
+ Children: do not apply slow intravenous route.
If an intravenous line is available: continuous intravenous infusion of adrenaline mixed with 0.9% saline sodium chloride for patients who have had a poor response to previous intramuscular injection and have received adequate fluids. Initiate infusion at 0.1 μg/kg/min, titrate every 3-5 minutes according to patient response. Combination of rapid infusion of 0.9% sodium chloride solution 1,000-2,000ml in adults, 10-20ml/kg in children over 20-30 minutes, can be repeated if necessary. In case there is a continuous intravenous line of adrenaline to maintain stable blood pressure, it is necessary to monitor pulse and blood pressure every 1 hour for 24 hours.

Note: 1 ampoule of 1mg adrenaline mixed with 250ml of 0.9% NaCl (so 1ml of dilution has 4μg of adrenaline).

Respiratory and circulatory support: Depending on the degree of respiratory failure and circulatory failure, one or several of the following measures can be used:
Breathing oxygen through a mask: Flow of 6-10 liters/minute for people adults, 2-4 liters/minute for children. Squeeze the oxygenated Ambu ball. Perform endotracheal intubation with oxygen if increased bronchospasm unresponsive to adrenaline. Tracheostomy in patients with glottis-hypopharyngeal edema who cannot be intubated. Slow IV infusion: Aminophyllin 1mg/kg/hour or salbutamol 0.1μg/kg/hour or terbutaline 0.1μg/kg/hour (preferably via an electric syringe or infusion machine). Aminophyllin can be replaced by salbutamol 5mg nebulized through a mask or throat spray salbutamol 100μg/kg, adults 2-4 puffs/time and children 2 puffs/time, 4 to 6 times/day. If BP cannot be raised to target after adequate fluid and adrenaline infusion, additional colloidal colloidal solutions (albumin, plasma, or any other available macromolecule solution) may be given.
- Other drugs:
Methylprednisolone dose 1-2mg/kg in adults, maximum 50mg in children or hydrocortisone 200mg in adults, maximum 100mg in children, can be injected intramuscularly or intravenously depending on specific conditions. Antihistamine H1: Diphenhydramine intramuscular or intravenous injection, adults 25-50mg, children 10-25mg. Antihistamine H2: Ranitidine adult 50mg, children 1mg/kg mixed in 20ml glucose 5% intravenously for 5 minutes. Glucagon: Used in cases of hypotension and bradycardia unresponsive to adrenaline. Dosage: Adults 1-5mg intravenously within 5 minutes, children 20-30μg/kg, up to 1mg then maintain intravenous infusion at a dose of 5-15μg/minute depending on clinical response. Care must be taken to ensure a good airway as glucagon can induce vomiting. Can be combined with other vasopressors: Dopamine, dobutamine, noradrenaline, intravenous infusion in case of severe shock when enough fluids and adrenaline are given but blood pressure does not rise.

In the acute phase: Monitor pulse, blood pressure, breathing rate, SpO2 and consciousness every 3-5 minutes until the disease is stable. In stable disease stage: Monitor pulse, blood pressure, respiratory rate, SpO2 and consciousness every 1-2 hours for at least the next 24 hours. All patients with anaphylaxis must be monitored at medical facilities for at least 24 hours after the disease stabilizes to prevent phase 2 anaphylaxis. Emergency Discontinuation: When emergency circulatory arrest has no results. In the case of a successful emergency, a stable patient should be seen by an allergist after 4-6 weeks. If you have a need for consultation and examination at Vinmec Hospitals under the national health system, please book an appointment on the website for service.

Source: BYT - Guidelines for diagnosis and treatment of some cancers